





































Clinical Medicine Insights
Received 16 Mar 2022 | Revised 18 Apr 2022 | Accepted 30 Apr 2022 | Published Online 13 May 2022

DOI: https://doi.org/10.52845/CMI/2022-3-2-1 
CMI 03 (02), 280−286 (2022) ISSN (O) 2694-4626 

RESEARCH ARTICLE

Sacroiliitis in patients with low backache with Normal Lumbosacral spine 
MRI

Dr. Bushra Mohsen Abdulla1* |  Dr. Fatimah Hameed Khairullah2

1MBCHB, Diploma of radiology, 
AlSader teaching hospital-Najaf 
health directorate
2 MBCHB, Diploma of radiology, 
AlHabobi teaching hospital-
Thiqar health directorate

Abstract
The detection and characterization of sacroiliac lesions on MR imaging has 
been well established, but its presence during evaluation of low backache 
cases has not been fully analyzed.
Aim: determine the presence of sacroiliitis in cases with low back ache 
found to have a normal lumbosacral spine MRI and analyze its prevalence 
and radiological patterns
Patients and Methods: A diagnostic study recruit   72 patients, they 
referred for lumbosacral spine MRI (1.5 Tesla) unit (16 channel coil) in Al-
Sader- Medical City between March and August of the last year.  Patients 
with abnormal LSS MRI were excluded .Information was taken from all 
patients about past medical and surgical history. Patients with normal LSS 
MRI  were further evaluated for SIJ fast spin echo MRI  applying the 
following study protocol: FSE coronal T1 WI & T2 WI STIR if abnormal 
finding seen then intravenous contrast gadolinium-DTPA about 0.1 mmol/ 
kg of body mass was injected and rescanned 10 minutes after injection to 
rule out the existing sacroiliitis or other SIJ abnormalities.
Results: 72 patients with mean age of 33.2 ± 10.11  years  ,male to female 
ratio was (1:2.483),  a small but significant number of patients with 
sacroiliitis seen in patients with normal LSS MRI, there was no significant 
statistical differences between patients with normal finding and those with 
sacroiliitis.  Three-fifth of the patients show narrowing of the joint space and 
one fifth show widening. The study revealed that all the patients had 
articular erosion and one fifth of the patients showed bone marrow edema. 
Conclusions: Sacroiliac joint lesions accounts small but significant number 
of lower backache patients. The enforcement of the diagnostic value and 
utility of adding a single fat suppressed sequence of the lumbo-sacral region 
in the coronal plane; adds marginally to the scan time but increases the yield 
of identifying incidental or manifest sacroiliac involvement in all cases 
referred for MRI for low backache.

Keywords: Sacroiliitis, Lumbosacral Spine, Magnetic Resonance Image.

MANUSCRIPT CENTRAL

used to avoid complications of hemodialysis manifested in uremic
state including anorexia, nausea, vomiting leading to malnutrition, fluid
and electrolyte imbalance leading to volume overload, hyperkalemia,
metabolic acidosis, and hyperphosphatemia, as well as abnormalities
related to hormonal or systemic dysfunction such as hypertension,
anemia, hyperlipidemia, and bone disease, Timely diagnosis of protein-
energy-wasting (PEW) is important for early initiation of nutritional
intervention and treatment. In addition, education plans should be
prepared to mediate the nutrient intakes and identify the patient’s
difficulties and provide practical help.
Keywords: Renal dialysis, Nutritional status, Hemodialysis, Malnutri-
tion

Copyright : © 2022 The Authors. Published by Publisher. This is an
open access article under the CC BY-NC-ND license
(https://creativecommons.org/licenses/by-nc-nd/4.0/).

CMI 03 (02), 280−286 280

https://doi.org/10.52845/CMI/2022-3-1-4
https://creativecommons.org/licenses/by-nc-nd/4.0/


1 INTRODUCTION

T he diagnosis of infectious sacroiliitis is 
difficult, many times delayed  because of its 
insidious clinical presentation with non-

specific and poorly localized signs, frequently 
simulating abdominal syndromes, lumbar 
discopathies or lumbosciatalgia. CT and MRI allow 
an earlier diagnosis, but are not able to define the 
etiologic agent. Generally radiographic alterations 
can be observed only two or three weeks after the 
first symptoms onset while on contrast-enhanced 
MRI, alterations can be observed within up to three 
days, showing MRI higher sensitivity (1-3). CT 
findings in the infectious process are the same of 
those observed in the sacroiliitis of 
spondyloarthropathies, except for the juxtarticular 
bone demineralization considered as the earliest 
finding besides signs suggestive of soft tissues 
involvement and unilaterally of the process(4). 
MRI, besides determining alterations in the affected 
sacroiliac joint and in the contiguous bone, also 
clearly demonstrates the involvement of adjacent 
soft tissues or collections, frequently posteriorly to 
the iliopsoas muscle these findings being highly 
suggestive of infectious involvement and not seen in 
spondyloarthropathies(1,3,4-7). The intravenous 
gadolinium injection can more accurately define 
these soft tissues involvement(4,5,7).

The main disadvantages of MRI are:

High cost, low availability, and long duration of 
examination (30 minutes) although the latter is well 
tolerated by the majority of patients included (1, 2 8, 
9) 10-16-13-18)
Aim of study: The aim of this study was to 
determine the presence of sacroiliitis in cases with 
low backache found to have a normal lumbosacral 
spine MRI and analyze its prevalence and 
radiological pattern.

2  |  PATIENTS AND METHODS

A diagnostic  correlative study done prospectively 
to include(72) patients (21male and 51 female) aged 
( 17-55 years)  at MRI Unit in Al-Sader-Medical 
City, Al- Najaf governorate/ Iraq for a period of six 
months (from March 2017 to August 2017).
All selected patients were already referred to the 
MRI unit for lumbosacral spine evaluation because 
of low backache.
LSS fast spin echo MRI was done for the patients 
using MRI machine Philips Acheiva 1.5 Tesla. The 
applied matrix was: 512X224, Slice width: 4 mm. 
Protocol of LSS MRI is: T2WI sagittal, T1WI 
sagittal, T2WI axial and T1 WI sagittal 

Qualitative and quantitative composition:

Active substance:
Dimeglumine gadopentetate 1ml aqueous injection 
solution contains 469 mg of gadopentetate 
dimeglumine (corresponding to 0.5 mmol of 
gadopentetate dimeglumine, corresponding to 78.63 
mg of gadolinium). Patients with normal LSS MRI 
were further evaluated &examines for SIJ MRI  by 
coronal T1 WI & T2 WI STIR if abnormal finding 
seen then we further evaluate the patient with 
intravenous contrast gadolinium (Magnevist® 0.5 
mmol/ml) about 0.1 mmol/ kg to rule out the 
existing SIJ abnormalities that explaining patient 
symptoms.
We evaluate the features of active inflammation; 
peri-articular bone marrow edema, synovitis and 
capsulitis/ enthesitis 
Peri-articular edema, visible as a region of increased 
signal intensity of bone marrow in fast spin 
echoT2weighted images, and the enhancement after 
contrast media administration  was evaluated in T1
+contrast image
Inclusion criteria: patients who have low back 
ache with normal LSS 

Supplementary information The online version of 
this article (10.52845/CMI/2022-3-2-1) contains 
supplementary material, which is available to autho-
rized users.

CMI 03 (02), 280−286 MANUSCRIPT CENTRAL 281



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Dr. Bushra Mohsen Abdulla ET al.

MRI, between the age of (17-55 year) were 
included.
Exclusion criteria: any patient with abnormal 
finding in LSS MRI examination was excluded from 
this study even if he/ she has abnormality in SIJ.
Data collection: Age, gender, past medical and 
surgical history documented in questionnaire.
Ethical consideration: Data and information of the 
participants were kept confidentially and not 
disclosed to unauthorized personal the study 
protocol was approved by the council of Faculty of   
Medicine/ Kufa University and the Department of 
Radiology, Official agreements were obtained, and 
Patients agreements were obtained.

Statistical analysis

Data of the studied group were entered and analyzed 
using the statistical package for social sciences, 
SPSS, version 24. Descriptive statistics presented as 
mean, standard deviation (for the age), frequencies 
and proportions (for categorical variables). Chi 
square test was used to compare patients with and 
without sacroiliitis with regard to age group and 
gender. Level of significance, P. value of less than 
or equal 0.05 was considered as significant. Results 
presented in tables and figures with an explanatory 
paragraph for each.   

The studied group consisted of 72 patients, with a 
mean age of 33.2 ± 10.11 (range 17 – 55) years, 
females were 51/72, represented 70.8% of the 
studied group, (figure 1 A and B).
According to the findings of the studied group, only 
7 patients (9.7%) had sacroiliitis, while the 
remaining 65 patients had not, (Figure 2).

3  |  RESULTS

Figure 1. A and B: Age and gender distribution of 
the studied group (N = 72)

Furthermore, the 7 patients with sacroiliitis were 
compared to those with no sacroiliitis regarding the 
age and gender, this comparison revealed no 
statistically significant differences between the two 
subgroups neither in age, nor gender, indicated that 
the incidence of sacroiliitis was insignificantly 
affected by the age or gender of the patient, in both 
comparison (P>0.05), (figure 3 A and B).
The clinical characteristics of the 7 sacroiliitis 
patients are shown in tables (3, 4, 5& 6) in addition 
to (figure 3. 2). 

MANUSCRIPT CENTRAL CMI 03 (02), 280−286 (2022) 282

Figure 2 Distribution of Sacroiliitis among the 
studied group



Figure 3A.Distribution of Sacroiliitis according to 
age of the studied group

Figure 3B: .Distribution of Sacroiliitis according to 
gender

Figure 4: Joint Space characteristics of the patients 
with sacroiliitis

Regarding the Joint Space characteristics, 
narrowing was reported in 5 patients (71.43%) and 
widening in 2 patients (28.57%), (figure 4).
The Lesion characteristics of the 7 patients with 
sacroiliitis revealed that all of them (100%) had 
Articular erosions, in addition, 2 patients had 
marrow edema (28.57%), (figure 5) .

Figure 5: Pattern of MRI in Sacroiliitis patients (N 
=7)

(Figure 5) summarizes the sacroiliitis patients MRI 
pattern,   including 5 narrowing, 2 widening joint 
space, 7 articular erosions and 2 marrow edema

CMI 03 (02), 280−286 (2022) MANUSCRIPT CENTRAL 283

 4  |  DISCUSSION

The true prevalence of sacroiliac joint lesions is 
unknown in most population groups, either with or 
without low backache. This study analyses the 
presence of sacroiliitis in MRI of lumbar spine 
referred for low backache, signifying the 
importance of this less highlighted entity in correct 
assessment of low backache. Low back ache is a 
common referral cause in routine MRI practice. 
Clearly, it is one of the most common symptoms 
evaluated and treated by practitioners. It has been 
observed in USA that annually a 15% to 20% of 
the population has an episode of lumbosacral pain 
with low back symptoms occurring in 50% of 
working age adults (1) Low backache is associated 



MANUSCRIPT CENTRAL
Dr. Bushra Mohsen Abdulla ET al.

with a wide range of clinical disorders. The 
commonest group is mechanical disorders, which 
occurs in more than 90% of all episodes of 
backache, 10% of the remaining patients with 
backache have symptoms related to systemic illness, 
like cancer, inflammatory back disease or infection 
(10  ).
In our study we found 28.57% of the patients had 
marrow edema in the evaluation of the sacroiliac 
joint. MRI of normal sacroiliac joint reveals an 
intermediate signal of the cartilage of the synovial 
compartment on T1 and T2 images limited by the 
signal void of bone cortex. On T1FSE and Fast 
STIR images the cartilage has an intermediate to 
high signal. The marrow on T1, T2 and T1FS 
images has a homogeneous intermediate signal. Fat 
suppressed images are extremely useful in imaging 
of cases with sacroiliitis. Fat suppression causes 
rescaling of signal intensities, categorizes cartilage 
as the brightest structure(6,9) This additive effect 
along with the darkened appearance of fat in 
adjacent soft tissues and sacral, iliac and lumbar 
marrow, renders improved visualization of 
structures and increases the conspicuity of lesion, 
thereby improving their pickup rate. There are two 
fat suppressed sequences that are available: T1-
weighted with fat suppression (T1FS) and fast short 
tau inversion recovery (Fast STIR) sequences. 
These are superior to T1 and T2 images, in 
demonstrating the changes of sacroiliitis(11).
The study was conducted by Hanly et al (12) has 
proposed that subchondral bone marrow edema is 
the earliest manifestation of the acute sacroiliitis, 
since 57% of their patients with subchondral bone 
edema did not present any sign of articular 
cartilaginous alteration. This theory is 
histopathologically corroborated by another study, 
by means of open biopsy in patients with initial 
stage of disease, where the earliest finding was 
subchondral inflammation. The sequence with 
highest sensitivity and specificity in detecting per 
articular bone marrow edema is the STIR sequence, 
since, differently from the conventional T2-
weighted spin-echo sequence, it saturates de fat, 
differentiating it from fluid (1, 11)).
The limitation of this finding — subchondral bone 
marrow edema — is that it also occurs in early 

phases of the degenerative process resulting from 
vascularization of fibrous tissue. For differentiating 
them, it is important to observe the site of the 
edema, i.e., hyper signal on the synovial portion of 
the sacroiliac joint indicates inflammatory disease, 
and, on the ligamentous portion, indicates 
degenerative disease(13) the patient's age should be 
taken into consideration, since osteoarthritis is 
frequent in elder, asymptomatic patients. These 
alterations are characterized by marginal 
osteophytes, subchondral sclerosis, and eventually 
articular fusion(8,14)  but unfortunately in our 
study we found that the incidence of sacroiliitis 
was insignificantly affected by the age or gender of 
the patient when compare to those with no 
sacroiliitis (p value more than 0.05) probably 
because of low sample size in this study. In normal 
population the sacroiliac joint space is influenced 
by age, gender, bone mass index and childbirth 
(15). Below the 40 years old the joint space is 2.49 
±0.66mm and above that age there is a high 
incidence of joint space narrowing (less than 2mm) 
and non-uniform joint space (15)33). Obese 
patients, multiparous women (with 3 or more child-
births) had a high prevalence of non-uniform joint 
space as well as shortening of joint space in 
multiparous women (15).
we found in our study 71.43% of the patients have 
narrowing and 28.57% of the patients have 
widening, this in agreement with Bigos et al(1) 
74% of the patients  show joint space narrowing. 
This is mean missing early detection of sacroiliitis, 
since narrowing of sacroiliac joint is consider as 
stage 3(1,8, 12,16) .
In our study we found 100% of the studied patients 
have articular erosion.
Partial volume artifact between the synovial and 
ligamentous compartments can be misinterpreted 
as erosions. There is normally a region of high 
signal at the immediate subchondral marrow, on 
Fast STIR images, which can be mistaken for early 
sacroiliitis. A patchy distribution of fat within the 
bone marrow as the sole finding should not be 
considered as an indicator for sacroiliitis(17,18) 

MANUSCRIPT CENTRAL CMI 03 (02), 280−286 (2022) 284



Low backache is one of the commonest referral in 
MRI scan centers .Sacroiliitis which is a 
demonstrable cause of low backache is often missed 
clinically or under estimate during routine MRI 
scanning of the lumber region. Sacroiliac joint 
lesions accounts for a small but significant number 
of low backache as evident from this study. This 
study highlights the diagnostic value and utility of 
adding a single fat suppressed sequence of the 
lumbo-sacral region in the coronal plane. This adds 
marginally to the scan time but increases the yield 
of identifying incidental or manifest sacroiliac 
involvement in all cases referred for MRI for low 
backache.

Recommendations:
1-To include fat suppressed sequence of LSS, 
coronal plane in every patients with LSS MRI
2-To emphasize and alert the clinician about the 
significance of sacroiliac joint as a cause for low 
backache.

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5 CONCLUSIONS

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Dr. Bushra Mohsen Abdulla ET al.

How to cite this article: Dr. Bushra Mohsen 
Abdulla ET al. Sacroiliitis in patients with low 
backache with Normal Lumbosacral spine MRI 
Clinical Medicine Insights. 2022;280−286. 
https://doi.or g/10.52845/CMI/2022-3-2-1

MANUSCRIPT CENTRAL CMI 03 (02), 280−286 (2022) 286

spondylitis: a proposal for modification of the New 
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no.14.AHCPR publication no. 95-0642. 
Rockville(MD): Agency for Health Care Policy and 
Reasearch, Public Health Service,US Department 
of Health and Human Services; 1994.


	Introduction
	Causes of nutritional disorder in HD
	Inadequate food intake
	Abnormal nutrient metabolism

	Aim and objectives
	Methodology
	Result 
	Assessment of nutritional status of HD. patients
	Prevalence of malnutrition using Subjective Global Assessment
	Body mass index in the study patients
	BMI and SGA score 
	 laboratory investigation 
	Association between nutrient intake and SGA

	Discussion
	Conclusions
	References



